Our mental health crisis

John F. Kennedy was one of our most visionary presidents. He set a ten-year goal for landing on the moon and, although he didn’t live to see it, the goal was met. He envisioned an agency, separate from the State Department, that would give American citizens the opportunity to live and serve as volunteers in developing countries around the world; and the Peace Corps became a reality. He envisioned, and provided funding for, a national mental health system, made up of local mental health centers, to replace the system where most mental health treatment was provided in large, centralized state institutions.

For most of my career as a psychologist, I was employed at community mental health centers (CMHCs). Little did I know when I started out in 1976, working for a CMHC in rural Alabama, that these were the halcyon days of our national mental health system. Mental health agencies had adequate funding to meet community needs. The plan was to decrease reliance on expensive (and often unnecessary) inpatient treatment in state “mental hospitals,” by providing outpatient mental health services at the local level. Almost all of the initial funding was federal dollars, with the understanding that the federal funds would gradually decrease, and states would allocate a portion of the money saved, to replace the federal funding for community outpatient treatment. The goal of the well-intentioned plan was called “de-instititutionalization.”

All across the country, states made plans to eventually shut down the massive institutions that often “warehoused” patients with chronic. severe mental disorders. This saved the states a lot of money over time, but the state legislatures failed to carry out their part of the plan and replace lost federal funding for community mental health treatment with state dollars. Instead, the money saved went straight into state general funds, and funding for community treatment gradually diminished, year after year. The range of services provided shrank over time. Community outreach and support services programs closed down and CMHCs became understaffed. Clinicians (like me) initially hired to provide individual, family and group therapy found themselves doing less therapy, and more and more bare-bones case management services for their ever-increasing caseloads of underserved clients. A lot of seriously mentally ill people received only occasional fifteen-minute medication management sessions with a psychiatrist.

With the big, centralized institutions shut down or downsized, and with the inability of most CMHCs to adequately meet community needs, across the country more and more people with mental illnesses and substance abuse problems have joined the ranks of the homeless. In many cities, hospital emergency departments stay backed-up because of all of the severely mentally ill people who need treatment and can’t get it elsewhere. Jails and prisons have become primary providers of (often inadequate) mental health services. Often, police officers are the first point of contact with people who are psychotic and out of control, sometimes with tragic results.

Few police officers are adequately trained to do effective interventions with manic and psychotic people. If the states had done their part and adequately funded community-based treatment, and we had the national mental health system that Kennedy envisioned, the first responder in a psychiatric crisis situation would be a social worker or a psychologist, not a cop. Police have enough responsibilities, without having to respond to psychiatric emergencies. Jails and prisons have enough problems to deal with, without having to be de facto mental health centers. Jails and prisons are obviously not environments conducive to stability and recovery.

Mental illness and substance abuse are some of the root causes of the rise in homelessness, and too many Americans are more judgmental than compassionate when they encounter homeless people. There remains in our society a stigma that brands mentally ill people as the Other, not as individuals whose impairments should be recognized and addressed on a societal level. Our national mental health system is a disgrace, partly due to stigma and the consequent marginalization of people with mental illnesses and substance abuse problems. We need to elevate our compassion for these people to the level of our compassion for people suffering from cancer and other physical diseases – maladies that have ad campaigns promoting awareness and compassion We need to treat substance abuse as more a public health issue than as a criminal issue.

Prevention is a vital part of medicine, and gets a lot of attention when it comes to physical illnesses. Kennedy’s plan emphasized prevention, and we need to develop a national model that puts the treatment of mental illness and substance abuse on a par with the treatment of physical injuries and diseases.

Why I write

Those of you who follow my blog may have wondered what’s happened to me, since I haven’t posted anything for months. I’m back, and I owe you an explanation. I plan to resume posting on a regular basis, but time will tell how frequently. I haven’t succumbed to the Plague. My only excuse is that in late May I injured my left knee in a fall, and required surgery. I realize that recovery from a knee injury doesn’t explain my silence as a writer; but it’s been part of a confluence of events that I’m trying to make sense of.

I knew from an early age that I wanted to be a writer, even though I didn’t know what I wanted to write about. It wasn’t just a fantasy about achieving fame or making money; I just knew that I had things to say. I read a lot and admired good writers.

I started out as a political science major in college, but discovered that my favorite classes were English literature courses. It didn’t take me long to switch majors. As a boy and as a teenager I’d mostly read adventure (including all of the Tarzan novels) and science fiction but, awed by the brilliance of such literary masters as Milton, Shakespeare and Goethe, I fell in love with literature. My first short story (science fiction) was published in The Citadel’s literary magazine, The Shako, and I served as poetry editor during my senior year. (Pat Conroy, The Citadel’s best-known alumnus author, held that job my freshman year.) It would be years before I wrote my next short story, but my brain was brimming with ideas.

Most of my fiction remains unpublished, but I hope that will change. I’ve written over a dozen short stories that I’m still proud of, as well as a crime novella and a speculative fiction novel. My two published books are non-fiction. Two years in Kingston Town is a memoir of my Peace Corps service in Jamaica (1991-93), with my wife Maria. Ad Nauseam: How Advertising and Public Relations Changed Everything, an examination of how we became a Propaganda Society, was the result of much research, and received several favorable reviews – including one in Kirkus Reviews. I had hoped it would be used as a textbook in high school and college social science and English classes, as an aid to teaching students about propaganda. But that didn’t happen.

Most writers — even good ones — have to get used to rejection and to persist in their efforts to get published. I’ve come to understand that what distinguishes true writers from dilettantes and people who write, motivated by fantasies of fame and money: we write because we must. I’ve said for years that writing is my therapy and, sure enough, now that I’ve had several unproductive months, I ‘ve been feeling that there’s something missing from my life. Writing is part of who I am. Whether it’s fiction or non-fiction, it’s like I get an idea in my head, and it wants to get out. So I start to put it into words, usually on paper for the first draft.

As I re-read and re-read the first draft, I make changes until I’m satisfied with it as a first draft. (Bestselling author James Michener said that he wasn’t a good writer, but was a very good re-writer.) I write my second draft on WORD, editing as I go, and print it out. As I read it over and over again, I continue to make improvements, polishing my prose until it says what I set out to say. Writing fiction, I continue to edit on WORD until I achieve what I consider a “final draft.” Blogging, as I type out my latest post on my WordPress blog site, I continue to find things to improve upon. So, what you read is a polished third draft.

At various times during my career as a psychologist, I wrote “You and Mental Health” columns for local newspapers. In them, I tried to de-mystify esoteric psychological concepts, and to educate readers about psychotherapy. While my father enjoyed my fiction, he told me that he most liked my mental health columns. He said that I had a gift for explaining complex things in layman’s terms. This praise and encouragement is part of what got me to start blogging.

Everyone is adapting — or trying to adapt –in their own way to this strange parenthesis in our lives that is the pandemic. I consider myself fortunate that I haven’t been significantly anxious or depressed, or afflicted by “cabin fever.” But that doesn’t mean that I haven’t been affected. The confluence of socially-distanced living and my knee injury seems to have temporarily sapped me of my creative momentum. I feel like I haven’t been fully myself lately. Until today, having written these words. It’s good to be back.

Improving your memory, Part 2

As regards memory, I believe there’s something to the notion “use it or lose it.” People who are convinced that they don’t have a good memory often don’t work to improve it. Excepting those who have a neurological memory deficit, it can become a negative cycle, a self-fulfilling prophesy. If you don’t trust your memory, you don’t use it; and because  you don’t use it, you don’t trust it.

In my last post I gave examples of mnemonic devices that you can use to improve your recall. I also described how I used a mnemonic device in concert with a behavior modification technique to change a targeted behavior problem. In this post I’ll share some things I’ve discovered about other mnemonic aids.

For instance, I’ve had a bad habit of leaving the stereo amplifier on – sometimes for a day or more – after playing a cd. I just didn’t notice that the little red power light was on. So I “amplified the signal”  by putting the cd jacket on the floor beside the sound system, and not picking it up until I’ve turned off the stereo.  Temporarily placing things where they don’t belong, but where you’re bound to notice them, is a simple mnemonic aid, when associated with a specific behavior.

Turning routine behavior patterns into mindful rituals has saved me a lot of frustration. I’ve programmed myself to always put my car key and my house key in the same place when I come home. This is probably obvious to most of my readers, but I’ve known a lot of people with memory problems who haven’t developed this simple habit. You can learn to do something mindfully until it becomes automatic. I have some obsessive-compulsive traits, and if I’m “on autopilot” when I leave the house, I might have anxious thoughts after I drive away: “Did I lock the door?” So, I’ve learned to lock the door mindfully, recording the act with the camera of my eyes. It’s a ritual, and it works. Teach yourself to be more frequently mindful of common tasks, and you’ll simplify your life. Never in my life have I lost a wallet, a credit card, or an important key. If I have a good memory, it’s because I’ve worked at it. You can, too.

As a writer, I’ve developed my own system to help me remember things and to connect ideas. I always keep index cards and a pen handy – in my shirt pocket when I’m out and about. If I have an  idea or come across something I want to remember, I jot it down. When the card gets crowded with ideas, it goes on The Pile, on my writing desk. Recent ideas are easy to find, near the top of The Pile. Then, every few weeks, I break out a legal pad and go through The Pile. Some pages on the pad are labeled, by topic or writing project. I record some items/ideas on the pages, line through others that I can’t use (“why did I write that down?”), and trash the index cards. Robert Pirsig, author of Zen and the Art of Motorcycle Maintenance, describes using a similar system in his follow-up book, Lila.

Sometimes I tear a blank page from a legal pad and use it to organize my thoughts for a project. I write down a working title and the first words that come to my mind (or from my index cards) on the topic. Then I “shotgun” any key words or related ideas from my head, onto the page. When I see associations, I may draw lines to connect items; or I may number items, to form a sequential outline. Most of my blog posts start with key words or index card notes, and what you read is a polished third draft. I write my first draft on a legal pad, my second on WORD, on my PC, and continue to refine from the WORD document as I transcribe my finished post.

Journaling is an excellent memory aid, especially if you’re a writer. Recording both thoughts and events aids your recollection of details in the months and years that follow, and is very helpful if you ever want to write a memoir or an autobiography. We tend to subconsciously edit our memories, and an honest journal can help you to remember what really happened. I kept a journal for the two years I served in the Peace Corps in Jamaica, and it enabled the writing of my first published book: Two Years in Kingston Town – A Peace Corps Memoir.

I’ve kept quotebooks since I was in grad school, so I have access to all of my favorite quotes. Ralph Waldo Emerson suggested that you “. . . make your own Bible. Select and collect all the words and sentences that in all your reading have been to you like a blast of triumph.” Over the years, I’ve started personalized quotebooks as unique gifts for family members and close friends, seeding them with quotes that I think will mean something to them, and leaving the bulk of the pages blank, to be filled with their own favorite quotes.

Finally, I’ve learned over time to use calendars as memory aids. Not only do I use the wall calendar in our kitchen to record upcoming appointments and trips, but I record birthdays for the coming year, and things like the date when the hummingbirds arrived last year – so I’ll know when to put out the hummingbird feeder. I now save each year’s calendar, as a historical record of when we did what. I hope that some of these suggestions have been useful in helping you to learn to trust, and improve, your memory.

The Peace Corps experience

Have you ever considered serving in the Peace Corps? Even before we got married in 1990, both Maria and I had, and we’d both lived abroad (Maria in Korea and me in Austria and Germany). Within weeks after our wedding we applied to serve as Peace Corps Volunteers (PCVs). At that time only one-in-three applicants was selected to serve. Would-be PCVs don’t typically choose where they’ll serve, although fluency in the language spoken is a given host country can be a determining factor. The more open you are to serving wherever your skill set is needed, the better your chances of selection. We were approved for service after a lengthy application process, and were selected by Jamaica. We had two weeks to decide if we’d accept Jamaica’s invitation, but it didn’t take us an hour after reading about our assignment to call Peace Corps headquarters in D.C. and accept. We put all of our belongings in storage, and sold our cars around the time we got our plane tickets in the mail.

The Peace Corps is an independent government agency, not a branch of the State Department. It currently has volunteers in over sixty developing countries around the world. PCVs aren’t sent to these countries to advance or influence American foreign policy, but rather to share their skills with host country nationals, in the service of sustainable development. Each volunteer serves within one of six sectors: education, health, agriculture, community economic development, youth in development, or environment. The host country, not the Peace Corps, decides how many volunteers in each sector they need, and where they will serve. Most PCVs serve for two years, after training.

In order to qualify for Peace Corps service, you have to be at least eighteen and in good general health. Most volunteers have at least a bachelor’s degree, but exceptions are made for people with experience in certain areas, including construction, business and forestry. To be accepted, you have to pass a physical (which the Peace Corps pays for) and establish that you’re not fleeing indebtedness or legal charges. People who’ve served in intelligence agencies like the CIA need not apply. You have to have a skill set (and in some cases, appropriate certification or licensure) that people in host countries need to support development projects. The largest sectors are education and health.

Some personal qualities that make for a good PCV are good people skills, self-confidence, autonomy, flexibility, and persistence in the face of obstacles. Peace Corps service is always an adventure, and sometimes an uphill struggle. As I wrote in my book, Two Years in Kingston Town: A Peace Corps Memoir, Peace Corps service can be likened to climbing a mountain; you wind up knowing more about yourself than about the mountain.

In most host countries, accepted applicants have to have three months of in-country training, including language lessons, before they’re sworn-in as PCVs and start their assignments. But since English is Jamaica’s official language, Maria and I only had six weeks of in-country training before we were sworn in (the same oath as when I joined the Army) and started working. Two things stand out from our training as development workers in Jamaica. The Peace Corps Country Director said something to the effect of, “If you think of Peace Corps service as ‘giving up’ two years of your life, Jamaica doesn’t need you that badly. You’re here to live in Jamaica for two years, and to learn as well as to teach.” A Swedish guest lecturer with years of experience in international development work said something like this: “For at least the first six months, keep your mouth shut, and your ears and mind open. Nobody needs to hear you telling them the right way to do things. You need to establish trust and credibility before you start offering advice.”

Maria taught psychiatric nursing, but had to get licensed as a Jamaican nurse before she could join the faculty at the School of Nursing. When we applied, having no idea where we’d serve, I thought I’d end up teaching English somewhere, as I have a B.A. in English. I never dreamed that I’d serve as a psychologist. But the University Hospital of the West Indies had just opened a detox/rehab ward for Jamaican addicts, and my skill set was just what they needed. So I served as the ward psychologist, and helped to develop a relapse prevention model for the ward.

As a PCV you don’t get paid a salary, but you get a living allowance that allows you to get by on the local economy. Every month you serve, a modest amount of money ($200 when we served) is set aside for your readjustment allowance, after you complete your service. Not all PCVs fulfill their two-year obligation. Some volunteers leave behind a lasting accomplishment,  however small, in terms of sustainable development in their sector; others don’t. But I still think that the Peace Corps gives more “bang for the buck” in terms of winning friends for the U.S. in developing countries than aid agencies like U.S.A.I.D., because Peace Corps service is all about developing helping relationships within host country agencies and Non-government Organizations (NGOs).

PCVs are citizen “goodwill ambassadors,” because they work at ground level with host country counterparts. After I was robbed on a bus in downtown Kingston, I heard a fellow commuter sympathetically refer to me as “jost a workin’ mahn” because – although white – I rode the bus to work, just like them. It was one of the best compliments I received while working in Jamaica.

Maria and I didn’t serve simply out of altruism or idealism. Peace Corps service was an opportunity for cultural enrichment and personal growth. We got to know the beautiful island of Jamaica, it’s people and culture. Not all PCVs leave behind an identifiable accomplishment in terms of sustainable development in their host countries; but Maria helped Jamaican nursing students to view mentally ill people as human beings first, and not as “mental patients.” I recently learned that the relapse prevention model I introduced on the detox/rehab ward is still being used at the University Hospital of the West Indies. Maria and I still echo what’s been called the “Peace Corps mantra”: we got more than we gave.

 

Peace Corps service in Jamaica

I only met one Jamaican psychologist during my two years living in Kingston, serving as a Peace Corps Volunteer. She told me that there were only a few psychologists on the island. The University of the West Indies, on the outskirts of Kingston, didn’t have a psychology department. When Maria and I applied for Peace Corps service after our marriage in 1990, I never dreamed that I’d be employed as a psychologist in whatever developing country invited us to serve. (The more open an applicant is to serving wherever his/her services are needed, the higher the likelihood of acceptance.) With a bachelors degree in English, I thought I’d end up teaching English somewhere near where Maria worked. Maria was a psychiatric nurse – easy to place – and our Peace Corps recruiter initially referred to me as her “ball and chain” – not so easy to place. Maria was selected by Jamaica to serve as an instructor at the University Hospital of the West Indies (UHWI) School of Nursing. It just so happened that UHWI had just opened Jamaica’s first detox/rehab ward (mainly for alcoholics and crack cocaine addicts) and was in need of a ward psychologist. So from 1991-93 I wound up being one of Jamaica’s few practicing clinical psychologists.

The ward was initially run by a young psychiatrist who had just finished his residency at Johns Hopkins, and the staff consisted mostly of nurses, none of whom had experience working exclusively with substance abusers. When I reported for duty I discovered that the 8-bed ward had no treatment model (other than the medical model) and I had no job description. The only thing resembling treatment was several Twelve Step meetings  a week.

So I told the staff what I was qualified to do and they encouraged me to write my own job description: I would interview each new patient, review his/her medical record, and write a clinical assessment, with recommendations for the treatment plan. I would serve as a member of the treatment team. I would conduct group therapy sessions (psycho-educational and process  groups), and do individual and family therapy as needed.

I knew the program really needed to be based on a valid treatment model if it was to be effective. Other than the ward psychiatrist, I was the only treatment team member to have had training in substance abuse treatment. I knew that my first task as a Peace Corps Volunteer (PCV) was to listen and observe and learn, and to win the trust and confidence of the rest of the treatment team before I started making suggestions. However, I also started to work on a relapse prevention model that I’d introduce once I’d earned my place on the treatment team. I wanted to co-lead my groups with staff nurses, but they repeatedly declined. They were content to monitor the sessions from the nursing station.

I initially felt somewhat anxious at the prospect of leading groups. I was confident that group dynamics would be the same in Jamaica as in the U.S., but I knew that I had things to learn about Jamaican cultural norms, and I hadn’t yet developed an ear for Jamaican patois. English is the official language and all educated Jamaicans speak it clearly, with that unmistakable accent. But all Jamaicans also speak patois, and “deep patois” is initially unintelligible to English speakers. An effective group leader has to stay on top of not only everything that’s said in group, but also the non-verbal communication within the group. My initial test came early-on.

In a group session with all males, after a heated exchange between “Clarence” and “Desmond,” I thought, Did I just hear a death threat? Indeed I had, and I did an immediate intervention: “Threats of violence are not allowed in group, gentlemen. I know it’s almost lunch time, but we’re not leaving this room until Clarence not only takes back his threat, but means  what he says.” Before the end of the session, Clarence had retracted his threat, and shook hands with Desmond. Jamaican men tend to be macho, and it took all of my group leadership skills to stay in control during some contentious sessions.

The nurses were relieved to learn that I could stand up to angry Jamaican addicts. They never had to call Security, no matter how heated things got in group. More than once I had to break up fights. Most of the addicts I worked with came to respect me, and most seemed to like me. Some requested that I work with them individually. My psycho-educational group sessions focused on the relapse prevention skills that I was incorporating into my treatment model.

I soon “earned my spurs” with the ward staff, and began to feel like a valued member of the team. Everyone seemed pleased with the quality of the clinical services I provided, and in my second year of service I introduced my relapse prevention model. I’d written a relapse prevention manual with workbook exercises such as “Identifying your triggers for relapse.” I printed and assembled it at the Peace Corps office, and provided copies to all staff and patients. The model and the manual were approved by the treatment team and adopted into practice. When I left, after Maria and I had completed our two years of service, I felt a sense of accomplishment. A fellow Returned Peace Corps Volunteer (“Once a PCV, always a PCV”) later told me that when he’d served at UHWI, a few years after my service, the manual was still in use.

Peace Corps service can be very challenging, and many PCVs aren’t able to accomplish what they set out to do in their assignments, due to circumstances beyond their control.  The Country Director said to our training group, “If you feel like you’re ‘giving up’ two years of your life to serve in the Peace Corps, Jamaica doesn’t need you. You’re here to live two years of your life among the people of Jamaica.” The Peace Corps Mantra is “I got more than I gave.” Our lives were enriched by our two years in Jamaica. You can read the whole story in my first book, Two Years in Kingston Town: A Peace Corps Memoir, available online at Amazon and Barnes & Noble. For those with an interest in cross-cultural therapy, the book contains vivid descriptions of some of my clinical interventions in therapy groups. But it also describes places on the island that tourists seldom see, daily life in Kingston, and encounters with all sorts of interesting people.